Monday, September 8, 2008

The biggest challenge in primary-care medicine is dealing with the complications of obesity, diabetes and hypertension.

We have drugs to treat the conditions. But we don't have potent enough public health measures, patient education and follow-up monitoring to avoid the heart attacks, strokes and chronic kidney problems that come with the modern disease territory.

At my office we use a disease registry to track our patients with diabetes, heart disease and high blood pressure. We use it to generate recall lists of people who are overdue for follow-up visits or lab tests. Most veterinary offices do that routinely, but not enough medical offices.

In an insurance-driven world where a high volume of office visits is the only practical way to earn a living, managing patients with multiple chronic diseases is a money loser. Seeing four patients over the course of an hour pays much better than helping a patient with complex problems for a full 60 minutes.

My office has invested heavily in an electronic medical record to track and monitor chronic conditions with little financial return.

Still, the system helped me notice that a patient's control of his diabetes had been slipping for a year. Repeating the mantra of diet and exercise wasn't getting us anywhere. He would promise to do better, yet the results never improved.

Adding more pills over the last year wasn't improving his blood sugar either. It was time for a radical lifestyle adjustment or the start of insulin. He wasn't happy about either option but reluctantly agreed to give insulin a go.

He has been coming into the office about four times a year. And his employer-based insurance was paying for his visits, but missing work to make appointments with me during normal business hours was costing him his attendance bonus and undermining my efforts to get tighter control of his diabetes.

We got around that by using email. He started sending me spreadsheets of his blood sugars every few days, and I gave him advice for adjusting his insulin and diet when he got off track. His blood sugar came down to near normal within two weeks.

Managing chronic diseases between visits is uncompensated work for doctors, yet the need for such care is huge.

The current financial disincentives to providing proper care for chronic disease are daunting, and the waste created by ignoring the problem is growing as the population ages.

Teaching patients to take care of themselves effectively should be paramount because it works. It's also cheap compared with a lifetime of drugs. Self-management makes all the difference in preventing long-term complications or avoiding a disease in the first place.